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� ' ' <br /> � Backtivater Preventior� Device <br /> d Property Owner Rebate Form <br /> Backwater Prevention Device Rebate Form <br /> Print and retum fhis forn, with your rebate package <br /> Property OHner Name: JEFF RICHTER _ <br /> Property address: 3406 LOMBARD <br /> City: EVERETT State: WA Zip: 98201 <br /> Mailing address (i(different):� �� L-1 � � � <br /> Cit . •� �C��— . . .� , State:�.lN �T - �Zip:_ _C''� .�� �' ,- <br /> Y:� -q <br /> E:mail address S '1�"•�Y� .Phone:..:�I_�'J—�-3�_7� / � <br /> 1- . <br /> �-. .-- -- - - <br /> Cost to install Backwater Prevention Device:��.���; - -- • • <br /> � Rebate Package Checlilist <br /> Please check that you have completed and included the/ollowing items in your <br /> submission. Items indicafed as(CONTRACTOFtJ will be provided to you by your <br /> confractor. <br /> I�The completed Backwater Prevention Device Rebate Form (this form) <br /> �Map of the property with location o( installed Backwater Prevention Device <br /> [CO TRACTOR] <br /> A copy of the completed Backuvater Prevention Device Final lnstallation Chec!<list <br /> [CONTRACTOR) <br /> �O�The itemized invoice showing business name, address, license number and detailed <br /> costs of installation and materials. [CONTRACTOR]. Note: No rebate wil!exr,eed fhe total <br /> cosf o/the installation of the 6ackwater prevention device work. <br /> / <br /> � �� A Vendor Payment Opfion Form signed by both the property owner and contractor IF <br /> you would like the City oi Everelt to pay the Contractor directly. Otherwise, the rebate <br /> check will be made out and delivered to you. <br /> / <br /> �C7 A completed and signed Form W-9 (Request for Taxpayer ldentification Number and <br /> Certification) <br /> Page 1 of 2 <br /> Revised 09/0912014 <br />